The American Association of Clinical Endocrinologists say that methyldopa or nifedepine are preferred in pregnancy

If preeclampsia – use magnesium sulfate

ACE inhibitors should be avoided in pregnancy because they are associated with fetal renal dysgenesis or death if used in second and third trimesters and cardiovascular or central nervous system malformations in the first trimester

Monitor

CBC, electrolytes, BUN, creatinine

Liver enzymes

Urine dip for protein and a 24-hour urine collection for creatinine clearance and protein excretion

Our Patient

Recommend discontinuing Lisinopril since it is an ACEI and start her on a beta blocker

Example: Labetalol or Propranolol for first line choice because it is not associated with mild fetal growth restriction like some other beta blockers are like Atenolol

Preeclampsia, which occurs after the 20th week of pregnancy, is characterized by new-onset or worsening hypertension, albuminuria, and hyperuricemia, sometimes with coagulation abnormalities. In some patients, preeclampsia may develop into a hypertensive urgency or emergency and may require hospitalization, intensive monitoring, early fetal delivery, and parenteral antihypertensive and anticonvulsant therapy.

Mild Preeclampsia : high blood pressure, water retention and proteinurea.

The diagnosis of hyperemesis gravidarum should lead to immediate hospitalization of an affected individual in order to restore fluids and replace electrolytes by infusing medication and fluids intravenously.

D5 NS bag containing 100mg thiamine given IV (banana bag)

Electrolyte deficiences are treated: K, Mg, and P are replaced as needed

Vitamin supplementation (particularly vitamins B6, C and thiamine) may also be recommended. Thiamine supplementation is specifically recommended to prevent the development of Wernicke's encephalopathy.

With these treatments, in many cases, vomiting may stop. If vomiting continues, antiemetic drug therapy may be recommended.

Food should not be given orally until vomiting stops and dehydration has been corrected.

Tube feeding or parenteral feeding is appropriate.

After vomiting stops, affected individuals should receive enteral nutritional supplementation as needed to calm nausea. Physicians should then slowly and carefully reintroduce fluids and small, frequent meals into an affected individual's diet. Meals should consist of foods that are high in carbohydrates and low in fat.

No drug is universally approved for treatment of hyperemesis gravidarum and few drugs are considered completely safe during pregnancy.

Choose the drug that targets the main symptom trigger (e.g. motion) she experiences. If there are many triggers, and/or her nausea and vomiting are more severe, start with serotonin antagonists . Intervene early if she has a history of hyperemesis gravidarum .

The risks associated with the medication must be assessed against the potential complications associated with prolonged starvation and dehydration.

Often effective in mothers who have multiple triggers (smell, motion, etc.), a history of hormone sensitivity, and/or moderate to severe vomiting. If a woman has a history of HG that responded to serotonin antagonists, it should be used early and as a first line drug to minimize severity.

IMPORTANT : Effects are dose dependent. Expensive intravenous therapies may sometimes be avoided if higher doses are used. Best taken on a strict schedule and weaned very slowly when asymptomatic for over two weeks. It is not uncommon for women to require this medication until delivery. Different brands may have different effects.

Effective for MILD cases of nausea and vomiting during pregnancy or as adjunctive therapy with more potent medications. Women mostly sensitive to motion may benefit most. Antihistamines with sedative effects can be helpful for sleep.

This class of drugs is helpful both for reflux and for prevention of gastric irritation which worsens nausea. They should be considered whenever a woman is vomiting frequently and/or cannot eat and drink sufficiently. Studies suggest they are safe during pregnancy. Mostly Class B drugs.

May be helpful in women who typically vomit after eating/drinking. Their main symptoms often are GI specific (motion sickness or sensitivity to light/sound) and these women may or may not respond to other medications such as Zofran. These drugs are sometimes used in conjunction with meds such as Zofran. Use with antihistamines to minimize side-effects.

FDA recommends this drug be taken for up to 12 weeks. Risks of serious side-effects increase thereafter.

Blocks dopamine receptors in the CTZ and increases the CTZ threshold & decreases the sensitivity of visceral nerves that transmit afferent impulses from the GI tract to the vomiting center. Class B Drug

Complications including reduced birth weight, increased risk of preeclampsia, increased risk of oral and lip clefts, and impaired fetal brain development have been reported when corticosteroids were administered during early pregnancy.

Women with hypothyroidism may have an exaggerated response to corticosteroids; thus any steroid should be used with caution in these mothers. Also, women with Type 1 Diabetes may require as much as a 40% increase in their insulin when high dose steroids are started.

Methylprednisolone is classified as pregnancy category C. Prednisone is classified as category B.

Women on bed rest often have significant pain due to atrophy, musculoskeletal changes and immobility. It often increases in the third trimester due to rapid fetal weight gain and growth. Use of these treatment modalities often assists in muscle relaxation and toxin release, thus having some increase in her sense of well-being.

Herbs

Horehound – has been used in traditional medicine to relieve morning sickness. Consult with an expert in botanical medicine before using during pregnancy.

Ginger – Three RCTs and one randomized crossover trial found that ginger reduced nausea and vomiting in early pregnancy.

The classic acupuncture point for nausea and seasickness, called Pericardium 6 is located in the middle of the inner wrist, three finger breadths away from the wrist crease, between the two tendons. RCTs show varying effectiveness.

Light Therapy

If a woman is unable to leave her home due to HG, consider full spectrum lighting to ease potential depression .

Hypnosis

Medical hypnosis may be used as an adjunctive treatment option for women with hyperemesis gravidarum. Controversy surrounds the benefit of hypnosis, but it has been studied in some cases of hyperemesis gravidarum and has been shown to be beneficial.